Vendor Application
Vendor Application
Attention Vendors:
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If you have questions about this application, please contact (704) 260-5600. All items or groups of items showing an “
*
” are mandatory and must be completed. Incomplete applications will not be processed.
Vendor Name:
*
Are you currently on the North Carolina list of debarred vendors?:
*
Are you currently on the North Carolina list of debarred vendors?:
*
Yes
No
Upon submission, the applicant certifies that: (i) Applicant is not listed on the Final Divestment List created by the State Treasurer pursuant to N.C.G.S. § 147-86.58 (the “Final Divestment List”), and (ii) Applicant will not utilize any subcontractor which is listed on the Final Divestment List. The Final Divestment List can be found on the State Treasurer’s website at the address www.nctreasurer.com/Iran and should be updated every 180 days.
Federal ID/SSN No:
*
Date of Application:
*
mm/dd/yyyy
Order Address:
*
Street:
City:
State:
Zip Code:
Order Email Address:
*
Remit Address:
*
If same as order address, enter "same" in street line.
Street:
City:
State:
Zip Code:
Contact Information:
Name:
*
Email Address:
*
Telephone Number:
*
Fax Number:
*
Date Established:
*
mm/dd/yyyy
Terms:
CCS Payment Terms Are Net30.
Discount:
Enter Discount Amount or leave as 0%
Contractor's License Number:
*
(If applicable. Otherwise enter NA)
Are you incorporated?:
*
Are you incorporated?:
*
Yes
No
For purposes of determining sales and use tax status, is your entity considered a “retailer” under N.C.G.S 105-164.3(35)?
*
For purposes of determining sales and use tax status, is your entity considered a “retailer” under N.C.G.S 105-164.3(35)?
*
Yes
No
M/WBE or HUB DESIGNATION: please read and complete as applicable (Minority/Women Business Enterprise or Historically Underutilized Business) Per NC General Statute 143-128.4, to qualify as a historically underutilized business, a business must be at least 51% owned, controlled and managed by one or more citizens or lawful permanent residents of the United States who are members of one or more of the following groups:
(1) Black, (2) Hispanic, (3) Asian American, (4) American Indian, (5) Female, (6) Disabled and (7) Disadvantaged
* Please check if you, as a sole proprietor are, or your business is:
*
Female Business Enterprise
Male Business Enterprise
Special Condition Enterprise
--Please Select--
Not Applicable
African American
Asian American
Caucasian
Hispanic/Latino
Native American/Indian
--Please Select--
Not Applicable
African American
Asian American
Caucasian (NON-MINORITY)
Hispanic/Latino
Native American/Indian
--Please Select--
Not Applicable
Disabled Business Enterprise(G.S.168-1 or G.S. 168-A3)
Disadvantaged(15 U.S.C. §637)
Non-Profit Work Center for the Blind and Severely Disabled
For State of North Carolina reporting purposes only, have you obtained M/WBE certification through the NC HUB office’s Statewide Certification (SWUC) program?
*
For State of North Carolina reporting purposes only, have you obtained M/WBE certification through the NC HUB office’s Statewide Certification (SWUC) program?
*
Yes
No
Pending
Vendors and their subcontractors with 25 or more employees in North Carolina as defined in Article 2 of Chapter 64 of the NC General Statutes must comply with E-Verify requirements to contract with Cabarrus County Schools. E-Verify is a Federal program operated by the US Department of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law. The following link outlines E-Verify requirements. http://canons.sog.unc.edu/?p=8248
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